Kaiser Permanente Nevada - Medical Director, Utilization and Referral Management and Authorizations

PRINCIPAL DUTIES & RESPONSIBILITIES

Responsibility

Description

Strategic Direction

· Implement KPNV business strategies and initiatives with the KPMF direction.

· Set high standards for themselves and the medical group, both around performance and around leadership style. Lead with integrity and respect.

· Represent KP NV to a variety of audiences both internal and external.

· Oversee the effectiveness, efficiency, service and quality outcomes of the medical, clinical, and business units that roll up to this leader. This includes:

o The referral management unit

o Review services (preservice, RRG)

o The clinical review unit (CRU)

o Provider reconsiderations

o Health plan UM activities and appeals in conjunction with Kaiser Foundation Health Plan of NV partners

o The division of EMS services, and case management

o Medical policy

Leadership and Teambuilding

· Oversee the EMS medical director on supporting novel initiatives and goal setting in the EMS space.

· Oversee Medical Policy medical director.

· Oversee the Case management medical director.

· Support a high performing medical group by setting clear expectations, reviewing outcomes, managing performance, and rewarding excellence.

Operational Excellence and Quality

· Oversee clinical and physician operational leaders in the areas reporting to them and ensures that those leaders and teams are leading work that is: 1. Aligned with our clinical intent, and 2. Meets the needs of our members in terms of the service experience and quality.

· Ensure teams meet the KPMF standards for review timelines and quality.

· Work with the CRU medical director and Mental Health and Wellness (MHW) Associate Medical Director to participate in the adjudication of hospital admission denials from Utilization Review and organizes CRU MD participation at weekly concurrent review meetings. Ensures weekend coverage for inpatient reviews as well as time sensitive outpatient reviews.

· Act as an expert liaison for KP NV treating providers and administrators who have complex utilization questions/issues, some of which are high profile and urgent. Able to respond to these issues in a timely and professional manner.

· Participate in various process improvement projects.

· Help bring on new medical policy initiatives and present resource requests to leadership.

· Utilize daily management system and operational excellence approach to daily work and escalation resolution.

· Meet KP NV compliance and code of conduct requirements.

· Ensure the Integrated Delivery System and Enterprise are successful by being an active, engaged, responsible partner in a variety of partnerships.

· Identify situations when benefit language is vague or contradictory, leading to difficulties with medical review decisions and forward these to the Benefits Committee.

· Provide consultation to local District and Specialty Medical Directors related to clinical review and review criteria and work with providers and staff to educate and orient them to the review criteria and process.

· Promote and support professional development and career satisfaction of front-line MD teams.

· Participate in the selection, evaluation, performance improvement, and recognition of providers.

· Initiate team meetings and one-on-one meetings with direct reports on an agreed-upon cadence.

· Meet annually with direct reports to review their individual development plans.

· Initiate, implement, and monitor Performance Improvement plans (PIPs) with support and assistance of management and Human Resources.

· Develop other leaders in the department and succession planning in partnership with Human Resources.

· Accountable for performance management in collaboration with Senior Leadership. Specific responsibilities include training, scheduling, selection, and orientation of new staff, setting expectations, giving feedback, recognizing excellence, promoting skill development, conducting performance evaluations and management, and celebrating successes of the medical group members.

Financial Stewardship

· Understand FTE and budget.

· Define optimal practice environment (tools, processes, equipment, etc.) to promote highly efficient physician practices, including review of all EWEP and stipends.

· Review and monitor all expenses, whether internal or external, and work across clinical sites and service areas to develop strategies that reduce overall costs.

· Participate and inform complimentary efforts in design and contracting as led by the Health Plan.

· Define the capital needs of the clinical department and program to ensure they have the tools needed to deliver quality care to our patients.

· FTE management and subspecialty decisions and partnership meetings will be done in accordance with both dyad partners and KP NV Business partner.

Other Skills and Knowledge

· Understanding of utilization review, case management, pathway development and management, and quality management. Good listening, writing and speaking skills. Ability to lead teams in program planning, implementation, and monitoring. Demonstrated skills in Lean RPIW processes.

· In addition to the above, knowledge of regulatory and certification requirements which impact utilization management, case management, referral management, and care coordination program design.